5 Functions Your Care Coordination Tool Must Have
By Marina Brown, BSN, RN, CCM, eQHealth Solutions Product Development Manager
Breaking down provider silos is going to require a practical tool that can drive coordinated care delivery. We cannot expect the traditional case management software systems to support a care coordination program. Care coordination software that is a few steps beyond care management software will also:
Make it easy for patients to adopt healthier lifestyles. Care coordination software makes it easier to follow the treatment plan and access providers by having one place for patients to:
• View their personal care plan, including all of their diagnoses and providers, and instructions for their medications.
• Send messages directly to their physicians and care coordinator.
• Locate and get directions to providers and community resources that are close to their home.
• Learn about their specific disease(s).
Quickly identify and monitor high risk patients. Care coordination software can track patients with higher usage of inpatient and emergency department services to focus resources on the neediest patients.
• Care coordinators can assign acuity levels based on patient assessments.
• Care coordinators can also assess patients’ health literacy levels throughout the course of the program.
• Changes in patients’ acuity and health literacy levels can be tracked over time to determine the effectiveness of interventions.
Increase time available for direct patient contact. Care coordinators can spend more time coaching patients on their conditions and better self-care with shortcuts, such as:
• Patient dashboards that provide a snapshot of medical history, the status of labs, clinical notes and personal issues that could be affecting the patient’s health. The care coordinator does not have to go through multiple tabs to find all this information.
• Built-in locator tool to find specialists and community resources, and work around barriers, such as transportation.
• Integration with benefits management, claims systems and Electronic Health Records (EHR) so that care coordinators do not have to view multiple systems for information.
Eliminate communication barriers between members of the care team. The primary care physician, for example, should be able to log into the program and instantly download a patient’s X-ray report that was ordered by another provider.
• Care coordination software brings together patient data in a central web-based information exchange where the primary care physician, specialists and the care coordinator can monitor patients referrals, access test results and physicians notes from the entire health team.
Drive best practices and efficient care with built-in features, including:
• Guidelines on national standards of care that providers can look up using a search tool or can be set to automatically trigger alerts when there are gaps in care.
For example, if there is no record of a patient having a cholesterol test within the last 12 months, the system will prompt a reminder to the physician that this test should be ordered.
• Physician profiles to monitor utilization, costs and quality measures.
• Pharmacy database that alerts when patient medications overlap and when there could be potentially life threatening interactions.
• Real time documentation of all team members’ activities to reduce duplicative procedures.
• Reports that track performance on multiple levels – from entire populations to individual providers and patients – to identify areas where quality and efficiency can be improved.
Marina Brown has been designing these types of systems for years and has become quite a subject matter expert. If you want to see first-hand what you should expect from care coordination software, she can give you at tour of at least one product that delivers all that and more, email her at email@example.com.
More on how to use care coordination software to reduce costs and improve quality is available here.